1. IMPULSE CONTROL
DISORDERS
-Dr. Deepika Singh, 2nd Yr Resident,
Dept of Psychiatry, GSMC & KEMH

2. IMPULSE CONTROL DISORDERS NOT
ELSEWHERE CLASSIFIED:
(1) Intermittent explosive disorder,
(2) Kleptomania,
(3) Pyromania,
(4) Pathological gambling,
(5) Trichotillomania, and
(6) Impulse-control disorder not otherwise
specified (NOS).

3. •
•
•
•
Epidemiology
Comorbidity
Etiology
Diagnosis & Clinical
features
• Course & prognosis
• Treatment

4. INTERMITTENT
EXPLOSIVE
DISORDER

5. Epidemiology
• More common in men than in women.
• More in first-degree biological relatives
of persons with the disorder than in the
general population
Comorbidity
• Higher association with pyromania
• Other disorders of impulse control
• substance use and mood, anxiety, and
eating disorders have also been
associated

6. • ETIOLOGY
Psychodynamic Factors:
• Explosive outbursts occur as a defense
against narcissistic injurious events.
• Rage outbursts serve as interpersonal
distance and protect against any further
narcissistic injury
Psychosocial Factors:
• Unfavorable childhood environment
• Early frustration, oppression, and hostility
have been noted as predisposing factors.

7. Biological Factors
• Low levels of CSF 5-HIAA have
been correlated with impulsive
aggression
• Decreased serotonergic
transmission, decreases the effect
of punishment as a deterrent to
behavior.
• High CSF testosterone correlated
with aggressiveness and violence
in men

8. DSM-IV-TR DIAGNOSTIC CRITERIA
• Several discrete episodes of failure to resist aggressive
impulses that result in serious assaultive acts or
destruction of property.
• The degree of aggressiveness expressed during the
episodes is grossly out of proportion to any precipitating
psychosocial stressors.
• The aggressive episodes are not better accounted for
by another mental disorder (e.g., antisocial personality
disorder, borderline personality disorder, a psychotic
disorder, a manic episode, conduct disorder, or
attention-deficit/hyperactivity disorder) and are not due
to the direct physiological effects of a substance or a
general medical condition

9. DIFFERENTIAL DIAGNOSIS
• Conduct disorder:
repetitive & resistant pattern of behavior, as opposed to
an episodic pattern.
• Antisocial and borderline personality disorders:
Aggressiveness & impulsivity are part of patients'
character & are present between outbursts.
• Schizophrenia: patients show violent behavior in
response to delusions and hallucinations, and they show
gross impairments in reality testing.
• Amok : It is an episode of acute violent behavior for which
the person claims amnesia. Amok is distinguished from
intermittent explosive disorder by a single episode and
prominent dissociative features.

10. COURSE AND PROGNOSIS
• It may begin at any stage of life, but
usually appears between late
adolescence and early adulthood
• The disorder decreases in severity
with the onset of middle age

11. TREATMENT
• Group psychotherapy & family
therapy
• Goal of therapy:
To have the patient recognize and
verbalize the thoughts or feelings
that precede the explosive outbursts
instead of acting them out.
• Anticonvulsants like carbamazepine,
valproate and phenytoin
• Selective serotonin reuptake
inhibitors (SSRIs)

12. KLEPTOMANIA

13. EPIDEMIOLOGY
Prevalence estimated around 0.6 %
Male-to-female ratio: 1:3
COMORBIDITY
• High lifetime comorbidity of affective
disorder (usually, but not
exclusively, depression) and various
anxiety disorders.
• Other impulse-control disorders
(notably, pathological gambling and
compulsive shopping), eating &
substance abuse disorders

14. ETIOLOGY
• Anna Freud pointed out that the
first thefts from mother's purse
indicate the degree to which all
stealing is rooted.
• Karl Abraham wrote of the central
feeling of being neglected, injured,
or unwanted.

15. • One theoretician established 7 categories of stealing in
chronically acting-out children:
1) As a means of restoring the lost mother child relationship
2) As an aggressive act
3) As a defense against fears of being damaged (perhaps a
search by girls for a penis or a protection against
castration anxiety in boys)
4) As a means of seeking punishment
5) As a means of restoring or adding to self-esteem
6) In connection with, and as a reaction to, a family secret
7) As excitement (lust angst) and a substitute for a sexual
act
• One or more of these can also apply to adult kleptomania

16. DSM-IV-TR DIAGNOSTIC CRITERIA FOR
KLEPTOMANIA
• Recurrent failure to resist impulses to steal objects that are not
needed for personal use or for their monetary value.
• Increasing sense of tension immediately before committing theft
• Pleasure, gratification,or relief at the time of committing theft
• The stealing is not committed to express anger or vengeance
and is not in response to a delusion or a hallucination.
• The stealing is not better accounted for by conduct disorder, a
manic episode, or antisocial personality disorder.

17. ICD – 10 PATHOLOGICAL
STEALING (KLEPTOMANIA)
• There are two or more thefts in which
the individual steals without any
apparent motive of personal gain or
gain for another person.
• The individual describes an intense
urge to steal, with a feeling of tension
before the act and relief afterward

18. COURSE AND PROGNOSIS
• Onset : late adolescence.
• Mean age
men : 50 yrs & women : 35 yrs
• Course: waxes & wanes, but tends
to be chronic
• Prognosis with treatment can be
good, but few patients come for
help

19. TREATMENT
• Behavior therapy,
including systematic
desensitization, aversive
conditioning
• SSRIs, such as fluoxetine
& fluvoxamine, appear to
be effective in some
patients

20. PYROMANIA

21. EPIDEMIOLOGY
• Prevalence : unknown
• Male to female ratio : 8 to 1
COMORBIDITY
• Substance abuse disorder & affective disorders;
• Other impulse control disorders, such as kleptomania in
female fire setters;
• Personality disturbances, such as antisocial &
borderline personality disorders.
• Attention-deficit disorder and learning disabilities may
be associated with childhood pyromania;
• Persons who set fires are more likely to be mildly
retarded than are those in the general population.

22. ETIOLOGY
Psychosocial
• Freud saw fire as a symbol of sexuality.
• He believed the warmth radiated by fire evokes the same
sensation that accompanies a state of sexual excitation, and a
flame's shape and movements suggest a phallus in activity.
• Some patients with pyromania are volunteer firefighters who set
fires to prove themselves brave, to force other firefighters into
action, or to demonstrate their power to extinguish a blaze.
• The act is a way to vent accumulated rage over frustration
caused by a sense of social, physical, or sexual inferiority.

23. • Several studies have noted that the fathers of patients with
pyromania were absent from the home.
• One explanation of fire setting is that it represents a wish
for the absent father to return home as a rescuer, to put
out the fire, and to save the child from a difficult existence.
Biological Factors
• Low CSF levels of 5-HIAA and 3-methoxy-4hydroxyphenylglycol (MHPG) - It suggests possible
serotonergic or adrenergic involvement.

24. DSM IV TR : PYROMANIA
• Deliberate & purposeful fire setting on more than one occasion.
• Tension or affective arousal before the act.
• Fascination with, interest in, curiosity about, or attraction to fire
and its situational contexts
• Pleasure, gratification, or relief when setting fires, or when
witnessing or participating in their aftermath.
• The fire setting is not done for monetary gain, as an expression
of sociopolitical ideology, to conceal criminal activity, to express
anger or vengeance, to improve one's living circumstances, in
response to a delusion or hallucination, or as a result of
impaired judgment (e.g. dementia, MR, substance intoxication)
• The fire setting is not better accounted for by conduct disorder,
a manic episode, or antisocial personality disorder

25. • ICD – 10 PYROMANIA
• There are two or more acts of fire setting without
apparent motive.
• The individual describes an intense urge to set fire to
objects, with a feeling of tension before the act and relief
afterward.
• The individual is preoccupied with thoughts or mental
images of fire setting or of the circumstances
surrounding the act (e.g., abnormal interest in fire
engines or in calling out the fire service

26. COURSE AND PROGNOSIS
• Begins in childhood, the typical age of onset
is unknown.
• When onset is in adolescence or adulthood,
the fire setting tends to be deliberately
destructive.
• It is episodic & may wax & wane in
frequency.
• Prognosis for treated children is good, and
complete remission is a realistic goal.
• Prognosis for adults is guarded, because
they frequently deny their actions, refuse to
take responsibility, are dependent on
alcohol, & lack insight

27. TREATMENT
• Treatment difficult because of their lack of
motivation.
• No single treatment has been proved effective;
thus a number of modalities, including behavioral
approaches, should be tried.
• Because of the recurrent nature, any treatment
program should include supervision of patients to
prevent a repeated episode of fire setting.
• In children and adolescents, treatment should
include family therapy

28. PATHOLOGICAL
GAMBLING

29. EPIDEMIOLOGY
• Prevalance ~ 1%
• Male to female ratio: 3:1
• Family histories of pathological
gamblers show an increased rate of
substance abuse and depressive
disorders.
• A parent or influential relative of the
patient often has been a problem or
pathological gambler.
• The family circle is likely to be
competitively & materialistically oriented,
evincing intense admiration for money &
associated symbols of success.

30. COMORBIDITY
• Mood disorders (especially, major
depression and bipolarity) &
substance abuse disorders ( alcohol &
cocaine abuse, caffeine & nicotine
dependence)
• ADHD
• Personality disorders ( narcissistic,
antisocial & borderline personality
disorders)
• Other impulse-control disorders.
• Although many have obsessive
personality traits, full-blown OCD is
uncommon.

31. ETIOLOGY
Psychosocial Factors
Predispose factors :
• loss of a parent, separation, divorce, or
desertion before child is 15 yrs of age;
• inappropriate parental discipline
(absence, inconsistency, or harshness);
• exposure to & availability of gambling
activities for adolescents;
• family emphasis on material and
financial symbols; and lack of emphasis
on saving, planning, and budgeting.

32. Biological Factors
• Subnormal MHPG concentrations in
plasma, increased MHPG
concentrations in the CSF, and
increased urinary output of
norepinephrine.
• Serotonergic regulatory dysfunction
• Chronic gamblers have low platelet
monoamine oxidase (MAO) activity, a
marker of serotonin activity.
• increased cortisol levels in the saliva of
gamblers while they gamble, which can
account for the euphoria that occurs
during the experience and its addictive

33. DSM-IV-TR PATHOLOGICAL GAMBLING
A] Persistent and recurrent maladaptive gambling behavior
as indicated by five (or more) of the following:
1] preoccupied with gambling (e.g., preoccupied with reliving past
gambling experiences, handicapping or planning the next
venture, or thinking of ways to get money to gamble)
2] needs to gamble with increasing amounts of money in order to
achieve the desired excitement
3] repeated unsuccessful efforts to control, cut back, or stop
gambling
4] restless irritable when attempting to cut down or stop gambling
5] gambles as a way of escaping from problems or of relieving a
dysphoric mood (e.g, feelings of guilt ,anxiety, depression)

34. 6] after losing money gambler often returns another day to get
even (chasing one's losses)
7] lies to family members, therapist, or others to conceal the
extent of involvement with gambling
8] committed illegal acts such as forgery, fraud, theft, or
embezzlement to finance gambling
9] jeopardized or lost a significant relationship, job, or
educational or career opportunity because of gambling
10] relies on others to provide money to relieve a desperate
financial situation caused by gambling
B] The gambling behavior is not better accounted for by a
manic episode

35. ICD–10 PATHOLOGICAL GAMBLING
• Two or more episodes of gambling occur
over a period of at least 1 year.
• These episodes do not have a profitable
outcome for the individual but are
continued despite personal distress &
interference with functioning in daily living
• The individual describes an intense urge
to gamble which is difficult to control and
reports that he or she is unable to stop
gambling by an effort of will.
• The individual is preoccupied with
thoughts or mental images of the act of
gambling or the circumstances
surrounding the act

36. COURSE AND PROGNOSIS
• Begins in adolescence for men and late in life for women.
• waxes and wanes, tends to be chronic.
Four phases :
1] winning phase: ending with a big win, which hooks patients
2] progressive-loss phase: patients structure their lives around
gambling, take considerable risks, cash in securities, borrow
money, miss work, & lose jobs.
3] desperate phase: frenzied gambling with large amounts of
money, not paying debts & huge loans.
4] hopeless stage: accepting that losses can never be made up,
but the gambling continues because of the associated arousal
or excitement.

37. TREATMENT
• Gamblers Anonymous was founded in
Los Angeles in 1957 and modeled on
Alcoholics Anonymous (AA); it is
accessible in large cities and is an effective
treatment for gambling in some patients.
• GA is a method of inspirational group
therapy that involves public confession,
peer pressure, and the presence of
reformed gamblers (as with sponsors in
AA) available to help members resist the
impulse to gamble.
• Four places in india, 2 in mumbai, 1 delhi &
1 chenai

38. • Cognitive-behavioral therapy (e.g.,
relaxation techniques combined with
visualization of gambling avoidance)
• Family therapy
• Little is known about the efficacy of
pharmacotherapy. One study
reported that 7 of 10 patients
remained completely abstinent over
8 weeks after taking fluvoxamine

39. TRICHOTILLOMANIA

40. EPIDEMIOLOGY
• Prevalence 0.6 to 3.4 %
• male to female ratio 1:9
• childhood type of trichotillomania
occurs approximately equally in girls
and boys.
• It is said to be more common than the
adolescent type and is generally far
less serious dermatologically and
psychologically.
• 33 to 40 % of patients chew or swallow
the hair that they pull out. Of this
group, approximately 37.5 % develop
potentially hazardous bezoars.

41. COMORBIDITY
• Significant comorbidity is found
between trichotillomania and OCD
(as well as other anxiety disorders);
• Tourette's syndrome; affective
illness, especially depressive
conditions; eating disorders; and
various personality disorders
particularly obsessive-compulsive,
borderline, and narcissistic
personality disorders.
• Comorbid substance abuse disorder
is not encountered as frequently as it
is in pathological gambling,

42. ETIOLOGY
• Disturbances in mother-child
relationships, fear of being left
alone, and recent object loss are
often cited as critical factors
contributing to the condition.
• Depressive dynamics are often cited
as predisposing factors, but no
particular personality trait or disorder
characterizes patients.
• Family members of trichotillomania
patients often have a history of tics,
impulse-control disorders, and
obsessive-compulsive symptoms

43. DSM IV TR : TRICHOTILLOMANIA
• Recurrent pulling out of one's hair resulting in noticeable hair
loss.
• An increasing sense of tension immediately before pulling out
the hair or when attempting to resist the behavior.
• Pleasure, gratification, or relief when pulling out the hair.
• The disturbance is not better accounted for by another mental
disorder and is not due to a general medical condition (e.g., a
dermatological condition).
• The disturbance causes clinically significant distress or
impairment in social, occupational, or other important areas of
functioning

44. COURSE AND PROGNOSIS
• Mean age at onset : early teens,
mostly before age 17
• Course is not well known; both
chronic and remitting forms occur.
• An early onset (before age 6) tends
to remit more readily and responds
to suggestion, support, and
behavioral strategies.
• Late onset (after age 13) is
associated with an increased
likelihood of chronicity and poorer
prognosis

45. • TREATMENT
• Psychopharmacological methods
- It includes topical steroids and
hydroxyzine hydrochloride , an
anxiolytic with antihistamine
properties; antidepressants;
serotonergic agents; &
antipsychotics.
• Patients who respond poorly to
SSRIs may improve with
augmentation with pimozide, a
dopamine receptor antagonist.
• Behavior therapy also helpful

46. IMPULSE-CONTROL DISORDER NOT
OTHERWISE SPECIFIED
COMPULSIVE BUYING
DERMATILLOMANIA
INTERNET ADDICTION
COMPULSIVE SEXUAL BEHAVIOR
MOBILE PHONE COMPULSION

47. COMPULSIVE
BUYING

48. -Originally referred to as
oniomania and
recognized by Emil
Kraeplin and Eugen
Bleuler.
-Compulsive buying is not
listed as a separate
diagnostic category in
DSM-IV-TR and ICD-10.
-Epidemiology:
• 1.1 to 5.9% prevalence
• More common in women
than in men

49. DIAGNOSTIC CRITERIA FOR COMPULSIVE BUYING
• Maladaptive preoccupation with buying or shopping, or
maladaptive buying or shopping impulses or behavior, as
indicated by at least one of the following:
– Frequent preoccupation with buying or impulses to buy that
are experienced as irresistible, intrusive, and/or senseless.
– Frequent buying of more than can be afforded, frequent
buying of items that are not needed, or shopping for longer
periods of time than intended.
• The buying preoccupations, impulses, or behaviors cause
marked distress, are time consuming, significantly interfere with
social,occupational functioning, or result in financial problems.
• The excessive buying or shopping behavior does not occur
exclusively during periods of hypomania or mania.

50. • Etiology: Psychodynamic theories
have implicated low self-esteem,
anxiety, and the need to reduce
stress as the causal factors.
• Comorbid conditions: Other
impulse control d/o’s (e.g.
kleptomania), mood d/o’s & OCD
• Course & prognosis: Onset :18 yrs
However, patients do not seek
treatment until their 30s, usually
because they have developed
serious financial problems.
- Patients often try to limit their
behavior but are unsuccessful.

51. TREATMENT :
• Treatment of compulsive buying is
difficult.
• Some patients are helped with
supportive therapy,& self-help
groups, such as Debtors Anonymous
• Pharmacological therapies include
antidepressants, anxiolytics, and
antipsychotics to treat any comorbid
conditions.
• The SSRIs have been used to limit
compulsive behavior and may be of
use in this condition, which has
compulsive aspects

52. INTERNET
COMPULSION

53. • Internet addiction disorder was
originally proposed by Ivan
Goldberg in 1995. It is however not
included in the DSM IV & proposed
to be included in DSM V.
• Such persons spend almost all their
waking hours with the computer
• Their patterns of use are repetitive
and constant, and they are unable
to resist strong urges to use the
computer or to surf the Web.
• Internet addicts may gravitate to
certain sites that meet specific
needs (e.g., shopping, sex, and
interactive games, among others).

54. Mark D. Griffiths’ 5 criteria of Internet
addiction are:
• Salience: Using the Internet dominates
the person’s life, feelings and behaviour.
• Mood modification: The person
experiences changes in mood when
using the Internet.
• Tolerance: Increasing amounts of
Internet use are needed to achieve the
same effects on mood.
• Withdrawal symptoms: If the person
stops using the Internet, they experience
unpleasant feelings or physical effects.
• Relapse: The addict tends to relapse
into earlier patterns of behaviour, even
after years of abstinence or control.

55. DERMATILLOMANIA

56. • Dermatillomania (also known as
neurotic excoriation, pathologic skin
picking, compulsive skin picking or
psychogenic excoriation) is an
impulse control disorder
characterized by the repeated urge
to pick at one's own skin, often to the
extent of causing damage.
• It includes an uncontrollable urge to
pick one's skin in order to seek
gratification.
Epidemiology
• Prevalence: 1.4 to 5.4%
• More common in females than males

57. ETIOLOGY:
- It is a coping mechanism to deal
with elevated levels of arousal or
stress within the individual, & that
individual has an impaired stress
response.
- According to psychosocial theory
picking behavior is the result of
repressed rage felt toward
authoritarian parents
COMORBIDITY:
mood & anxiety disorder, substance
abuse, trichotillomania, anxiety d/o,
major depressive d/o, obsessivecompulsive d/o,body dysmorphic d/o

58. COMPULSIVE
SEXUAL
BEHAVIOR

59. • Some persons repeatedly seek
out sexual gratification, often in
perverse ways (e.g
exhibitionism)
• They are unable to control their
behavior
& may not experience feelings
of guilt after an episode of
acting-out behavior.
• Sometimes called sexual
addiction

60. MOBILE
PHONE
COMPULSION

61. • Some persons compulsively
use mobile phones to call
others, friends,
acquaintances, or business
associates.
• They justify their need to
contact others by giving
plausible reasons for calling;
but underlying conflicts may
be expressed in the behavior,
such as fear of being alone,
the need to satisfy
unconscious dependency
needs, or undoing a hostile
wish toward a loved one.